Case 1

Case Report: A 47 year old patient was hit by a truck and presented to
the emergency room with hemodynamic instability. There were multiple rib
fractures on the left side and an unstable pelvis. Ultrasound revealed a
retroperitoneal hematoma.

AP Pelvis

With return of a reasonable blood pressure following resuscitation
and the placement of a left chest tube,

S/P Lt Chest Tube

a rapid spiral CT (5 cuts) of the posterior pelvic ring was obtained.

Rapid Spiral CT

The CT showed transforminal sacral fracture on the right side and an ilium
fracture on the left. Because of the CT findings and a requirement for a
continuous extensive volume resuscitation , the patient was taken to the OR where
the posterior pelvic ring was stabilized with a C-clamp.

S/P C-Clamp

The patient became hemodynamically stable for 30 min. Just prior to leaving
the OR, the patient suddenly showed again all signs of circulatory collapse as
severe hemorrhage exited the Left chest tube.

Repeat CXR

An X-ray of the chest demonstrated a hemothorax on the left side. An immediate
thoracotomy was performed and 4 litres of blood were evacuated from the left
chest. The source of bleeding could not be identified and the patient died on the
table due to exsanguination.

An autopsy revealed the the C-clamp had effectively controlled bleeding
from the cancellous bone of the pelvic fracture surfaces. An arterial injury
was not found. Continuous bleeding from the completely disrupted presacral
venous plexus had caused extensive retroperitoneal hematoma which eventually
communicated with the left chest cavity and was accelerated by the evacuation
of the left chest tube.

Comment: This case serves as an important example that angiography, which
is routinely recommended by most pelvic bleeding algorithms, is not necessarily
an appropriate treatment either before or after "when all else fails".
With proper pelvic packing technique, the odds for the survival of this
patient would have been much improved.

As a result of this case, we have changed our diagnostic strategy and
now use lactate and base excess to estimate the real severity of hemorrhage.
Moreover, we now use the very aggressive treatment protocol with the combination
of C-clamp and pelvic packing. This has decreased our mortality to 25% in
patients in extremis which is far better than the mortality rate published
in similar studies.